Transcription of RAJYA SABHA SECRETARIAT Proforma for self …
1 RAJYA SABHA SECRETARIAT Proforma for self -certification by the Government employee I (Name of the Govt. servant) wish to confirm that I am (Home Town/ Any Place in India) LTC in respect of self / family member(s) for the block to (Place of visit) during ..(dates of journey). It is stated that I or the family member for whom I wish to avail LTC has/have not availed of the same before in the present block. 2. Particulars of members of family in respect of whom the Leave Travel Concession is being claimed are as under: Sl. No. Names (s) Age (in years) Relationship with the Govt. Servant 3. My parents/brother(s)/sister(s)/unmarried son(s)/unmarried daughter(s) are wholly dependent on me and have no source of income/income from all sources, including pension, temporary increase in pension but excluding dearness relief on pension or stipend etc. does not exceed Rs. 9,000/- 4. It is certified that the above facts are true and any false statement shall make me liable for appropriate action under Rule 16 of CCS (LTC) Rules, 1988 and the relevant disciplinary rules.
2 (Signature of Govt. servant) Name: Designation: Contact No.: Date: * : Government employee may share interesting insights and pictures, if any, of the destination visited while availing LTC on an appropriate forum.
